Concept Map This assignment is designed to extend the learner’s use of concept mapping as a tool for clinical care planning. The nursing process continues to provide the foundation for organizing info

Adrianna F. Pierson

NR 226: Fundamentals - Patient Care

Professor Thomas

September 16, 2020

Week 3 Clinical for Robert Jones

Questions and Answers

Questions:

1. What are your primary concerns for this patient and what assessments and interventions would be associated with your concerns and why?

2. What do you anticipate the patient’s home medications prior to admission might be and why?

3. What medications do you anticipate the health care provider would prescribe while the patient is in the hospital and why?

4. What medications would you anticipate the healthcare provider prescribing for the patient’s discharge and why?

Answers:

1. Concerns: Deficient knowledge, risk for infection or any adversity, pain, mobility, bone deformities, joint degeneration, muscle spasms, etc.

Assessments: Complete comprehensive assessment to include pain and pain history.

Interventions: Assess the client's level of understanding, risk for injury, risk for ineffective breathing patterns, risk for altered tissue profusion and deficient fluid volume, subjection of pain, historical experiences with pain and relief, identify things that cause aggravation, be mindful to determine nonverbal cues of the client that pain is present, and determine if the client is experiencing any emotional or physical distress, develop a care plan for pain relief, apply heat or ice therapies, reposition client frequently, remove any client stressors, reassess client comfort and pain prior to any activities and medically treat if necessary, make adequate time for client rest periods, make use of any adaptive equipment or devices as needed, educate and instruct the client on medication regimen, adverse reactions, contraindications, duration, and completion, determine fall risk, safety concerns, etc.

1. Pain medications: relieve pain

NSAIDs: anti-inflammatory

Muscle relaxants: relieve or relax painful muscle spasms

Corticosteroids: anti-inflammatory for musculoskeletal pain disorders

1. Pain or Anesthetics: control pain

Possibly:

Antibiotics: treat infection

1. Pain: relieve pain.

Other ways to manage pain: heat or ice applications

Reflection for Robert Jones

Nursing Diagnosis:

1. Impaired walking r/t compromised ability to move purposefully within the environment as evidenced by pain.

1. Impaired physical mobility r/t decreased muscle strength and endurance as evidenced by degenerative joint disease.

1. Impaired physical mobility r/t limited strength as evidenced by limited range of motion.

Priority Nursing Actions:

1. Acknowledge and accept the client's subjection of pain.

2. Educate and treat the client's pain with multimodal therapies.

3. Reposition client frequently (every two hours).

4. Medicate client before activities or relative procedures.

Nurse Note

Robert Jones is a 52-year-old male in postoperative care from an elective total right knee arthroplasty. He currently expressed having a new cramping pain in his right calf that is scored 8/10 on a scale from 0-10. He was admitted two days ago. He has a past medical history of chronic osteoarthritis. (App iHuman, 2020)

His vitals are stable for the most part. However, he is experiencing tachypnea. On his right calf there is an area of redness and 1+ pitting edema. The right calf is 3 cm wider in girth than the left calf. The patient complains of pain upon palpation of this calf. There are no diminished pulses in the right calf or lower extremities. Currently, Mr. Jones is refusing to wear the prescribed SCDs. The incision site is well-approximated with no redness, swelling, or drainage present at the site. Sutures are intact and peri-wound area is clean and dry. (App iHuman, 2020)

It is anticipated that the provider will visit Mr. Jones as soon as possible to evaluate and perform a thrombolytic assessment. I have made some recommendations and requested some relative items to include a doppler scan and lab tests. Patient is currently on bedrest with SCDs off despite nursing advisement and education. (App iHuman, 2020)

Thoughts and Considerations

The clinical taught me that consciousness is vital to the quality of care and communication provided by nurses. To first realize to be cognizant of the internal and external environment will incite the appropriate actions, connections, continuance of education, and professionalism. Having acquired this mindset, I further learned to identify that from the initial approach to accomplishing any nursing goal at hand is a process.

References

App iHuman. (2020). iHuman: Robert Jones. Retrieved September 16, 2020, from

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Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical Examination & Health Assessment (Eighth). Elsevier.